APPENDICITIS

Definition

•  Inflammation of the appendix

History

•  Diffuse/periumbilical pain → localizing to RLQ, anorexia, nausea, vomiting, irritability (may be the only sx in age <2), fever

Physical Findings

•  RLQ tenderness, rebound/guarding, Rovsing sign (RLQ pain w/ palpation in LLQ), psoas sign (RLQ pain w/ hip extension), obturator sign (RLQ pain w/ leg flexion + internal hip rotation)

Evaluation

•  Labs: CBC, UA (sterile pyuria/mild hematuria), hCG

•  Imaging: U/S (90% sens: Much lower if perforated/large habitus/operator dependent), abdominal plain films (fecalith 10%), CT scan (95% sens/spec)

Treatment

•  Surgical consult for operative management, abx (ampicillin 50 mg/kg, gentamicin 1 mg/kg + metronidazole 15 mg/kg or cefoxitin 20–40 mg/kg)

Disposition

•  Admit

Pearls

•  90% of children <2 y/o have perforation at presentation (thinner walled/looser omentum → ↑ perforation)

•  Young children may not have anorexia

INTUSSUSCEPTION

Definition

•  Invagination of bowel into another, most commonly ileocolic (most frequent cause of SBO in <6 y/o)

History

•  Age 3 mo–3 yr (peak 5–9 mo), lethargy, vomiting, intermittent fussiness/crying/inconsolability w/ drawing legs to chest, cramping abdominal pain

Physical Findings

•  Not tender b/w episodes, abdominal tenderness, RUQ sausage-like mass, heme + stool, “currant jelly” stool (late finding in <1/3 of pts)

Evaluation

•  Upright plain abdominal film to r/o free air: SBO/air outlining area/nl; U/S (definitive): Target, bull’s eye, doughnut, pseudokidney sign; barium/air/water enema: Diagnostic/therapeutic (90% successful)

Treatment

•  Barium/air/water enema, NGT, surgical consult for operative management in case barium enema fails, hydration (severe dehydration is common), NPO

Disposition

•  Admission for 24 h observation

Pearls

•  <3 y/o likely idiopathic

•  Barium enema is contraindicated if peritoneal signs

MALROTATION WITH MIDGUT VOLVULUS

Definition

•  Malrotation & weak fixation of the duodenum & colon during embryologic development → twisting of the mesentery causing duodenal obstruction/SMA compression → necrosis

History

•  Neonate (may be older), acute abdominal pain, bilious vomiting, ±distension, irritability/lethargy, FTT, mostly occur w/i 1st year of life

Physical Findings

•  Ill appearing/dehydration, heme + stool/grossly bloody, abdominal tenderness, often peritoneal

Evaluation

•  Upright plain films: “Double bubble” (dilated stomach & duodenum)/pneumatosis/SBO; U/S: “Whirlpool sign”; upper GI series (diagnostic): “Corkscrew sign”, coiled-spring appearance of jejunum

Treatment

•  Immediate surgical consult for operative management, NGT, NPO, abx, fluids

Disposition

•  Admission

INCARCERATED/STRANGULATED HERNIA

Definition

•  Defects in the abdominal wall that allow protrusion of abdominal contents through the inguinal canal

History

•  More commonly male, abdominal/groin/testicular pain, inguinal fullness w/ prolonged standing/coughing, vomiting, irritability in infants

Physical Findings

•  Intestine/BS in scrotal sac

Evaluation

•  Scrotal/abdominal U/S if physical exam is unclear, x-ray can be used to r/o free air

Treatment

•  Reduction: Place in Trendelenburg → gentle pressure ± ice analgesic/benzodiazepines; >12 h concern for perforation/gangrene → surgical management

Disposition

•  Admission if operative management required

MECKEL’S DIVERTICULUM

Definition

•  Omphalomesenteric duct remnant w/ 60% containing heterotopic gastric (80%) or pancreatic tissue

History

•  Any age (sxs usually begin <2 y/o), ±LLQ pain, melanotic stool (acid secretion → ulceration/erosion of mucosa), vomiting, sx of SOB, intussusception

Physical Findings

•  LLQ mass, heme + stool/brisk bleeding, abdominal distension

Evaluation

•  Technetium scan (Meckel’s scan): Identifies heterotopic gastric tissue (90% sens)

Treatment

•  Type & cross/transfuse for brisk bleeding, surgical consult for Meckel’s diverticulectomy

Disposition

•  Admit

NECROTIZING ENTEROCOLITIS (NEC)

Definition

•  Inflammatory condition of intestinal wall

History

•  Preterm neonate (10% full term), bilious vomiting, abdominal distension, bloody stool, feeding intolerance

Physical Findings

•  Ill appearing, hypotension, lethargic, abdominal tenderness, heme + stools, diarrhea

Evaluation

•  Abdominal x-ray: Pneumatosis intestinalis (75%); barium enema if x-ray is ambiguous

Treatment

•  NPO, hydration/transfusion, NGT, abx (ampicillin/gentamicin/metronidazole), surgical consult

Disposition

•  Admit

Pearls

•  Bell stages: I. Vomiting/ileus, II. Intestinal dilation/pneumatosis on x-ray, III. Shock/perforation

•  Cx: DIC, strictures, obstruction, fistulas, short gut syndrome

HIRSCHSPRUNG DISEASE

Definition

•  Absence of ganglion cells in the myenteric plexus of the colon → constant contraction & proximal dilation → constipation (4:1 male predominance)

History

•  Chronic constipation, delayed 1st meconium, FTT, abdominal distension, vomiting

Physical Findings

•  Palpable stool in abdomen, tight sphincter, fecal mass in LLQ, no stool in rectal vault, “squirt” – explosive release of stool when finger is withdrawn

Evaluation

•  Abdominal plain film: Dilated colon/fecal impaction/air fluid levels; barium enema; Dx → biopsy (aganglionosis) or anal manometry

Treatment

•  Outpt surgical eval

Disposition

•  D/c unless cx: Toxic mega colon, perforation, enterocolitis

CYANOSIS

Approach

•  Differentiate cyanosis that is central (mucous membranes, tongue, trunk, 2/2 right-to-left shunt) vs. peripheral (feet, hands, lips, 2/2 peripheral vasoconstriction)

Definition

•  Acrocyanosis: Blueness in hands/feet only seen in newborns 2° perfusion of the extremities → nl & resolves w/i 1st few days of life

•  Breath-holding spell: Prolonged period w/o attempt to breathe a/w intense crying from pain, anger, fright → benign, but Dx of exclusion

History

•  Age of onset, central or peripheral, med ingestion, recent illness

•  Change w/ crying: Improvement → respiratory etiology (↑ alveolar recruitment); exacerbation → cardiac etiology (↑ cardiac output)

Findings

•  Appearance (ill or well), VS, respiratory distress, heart murmur

Evaluation

•  Provide O₂, obtain CXR, ECG

•  Hyperoxygenation test: Compare ABG on RA & on 100% O₂ for 10 min, P_O2 of >250 excludes hypoxia 2/2 congenital heart dz

•  Improvement in O₂ sat w/ O₂, lack of murmur, nl ECG → pulmonary process

•  No change in O₂ sat w/ O₂, murmur, abnl ECG → cardiac cause → obtain echo (see 14-19)

Treatment

•  O₂, identify then tx underlying condition

•  Consider PGE₁ for pts <2 wk of age in circulatory failure

Disposition

•  Admit any pt who is ill appearing, low O₂ sat or PaO₂

•  Consult cardiology for any pt w/ suspected congenital cardiac dz

PEDIATRIC FEVER

Approach

•  Fever (38°C or 100.4°F) management is different in pediatric population than adults

•  ABCs, check O₂ saturation, rectal temperature

•  Need for abx & hospitalization depends on age, tox, exposures, immune status, identified source, seriousness of source

•  Introduction of H. influenzae & pneumococcal vaccines have changed the incidence & etiology of febrile illness in pediatric populations

FEBRILE INFANT 0–90 D OLD

History

•  Difficult to obtain localizing hx; standardized w/u to Dx serious bacterial illnesses

•  Exposures (travel, ill family members) & immunizations are helpful

Findings

•  Fever >38°C or 100.4°F rectal considered standard; fussy, irritable, poor feeding

•  Assess frequency & # of wet diapers, cap refill, fontanelles, tears, to estimate dehydration

•  Ask about any rashes (viral exanthems, meningococcus)

Evaluation

•  Sepsis w/u: See table

Treatment

•  Less than 1 mo: Cefotaxime 50 mg/kg IV q12h + ampicillin 25–50 mg/kg IV q8h

•  1–3 mo: Ceftriaxone 50 mg/kg IV q24h or IM ceftriaxone 50 mg/kg if being discharged

•  Higher doses for suspected meningitis, consider adding acyclovir 20 mg/kg IV (see 14-16)

•  Treat other identified bacterial source appropriately

•  If LP was not performed, consider withholding abx in well-appearing infant w/ nl WBC

Disposition

•  If <30 d or <90 d & toxic appearing, admit and follow cx even if all labs nl

•  Can d/c 30–90 d w/ negative sepsis w/u, well appearing/feeding after 1 dose ceftriaxone, f/u in 24 h

Pearl

•  Due to inability to localize source of infection, relative immaturity of immune systems & prevalence of occult bacteremia, all pts receive extensive sepsis w/u

FEBRILE CHILD 3–36 MO

History

•  Vulnerable immune system, esp to encapsulated organisms exposures

•  Exposures (travel, ill family members) & immunizations helpful

Findings

•  Irritable, poor feeding; elicit hydration status via # of wet diapers, tears, fontanelle, cap refill

•  Ask about any rashes (viral exanthems, meningococcus)

Evaluation

•  See table

Treatment

•  If ill appearing w/ fever, 1 dose ceftriaxone (80 mg/kg IV & 24-h admission for cx)

•  Treat identified bacterial source appropriately

Disposition

•  If well appearing w/ negative w/u:

•  WBC >15K (ANC >9000), give empiric abx (ceftriaxone IV or IM) & admit for 24-h observation

•  WBC <15K (ANC <9000), d/c w/o abx, but close f/u in 24–48 h

Pearls

•  Prevalence of occult bacteremia in well-appearing children <36 mo is now 0.25–0.4% (Acad Emerg Med 2009;16(3):220; Arch Dis Child 2009;94(2):144)

•  Rapid influenza testing may reduce further testing & interventions in febrile infants & children in the ED (Pediatr Infect Dis J 2006;25(12):1153)

JAUNDICE

Definition

•  Yellowish discoloration of the skin/tissue/body fluids caused by ↑ bilirubin production or ↓ excretion

Approach

•  Bilirubin: Formed from degradation of hemoglobin → bound to albumin in blood (unconjugated/indirect) → conjugated in liver by glucuronyltransferase (conjugated/direct) → excreted in bile

History

•  Differential depends on age (neonates ≤4 wk), gestational age, breast-feeding status

•  Time of onset of sx: Yellowing of skin, dark urine

Physical Findings

•  Scleral icterus, jaundice

Labs

•  Total/fractionated bilirubin (visible >5 mg/dL in neonates), LFTs, CBC (hemolysis/anemia → Coombs test, smear, ABO/Rh type), reticulocyte count, serum haptoglobin

•  Neonates → unconjugated (can be physiologic, treat to prevent kernicterus)/conjugated (always pathologic)

PHYSIOLOGIC JAUNDICE

Definition

•  Elevated unconjugated bilirubin in the 1st wk of life, 60% newborns will be jaundiced (peaks 2–5 d), due to low activity of glucuronyltransferase

Evaluation

•  Total/fractionated bilirubin, CBC (hemolysis/anemia → Coombs test, smear, ABO/Rh type), total bilirubin usually <6 mg/dL, up to 12 mg/dL in premature infants

Treatment

•  No tx necessary

Disposition

•  Home

Pearls

•  Pathologic: In the 1st 24 h of life, peak >17 mg/dL in breast-fed/>15 mg/dL in formula-fed infants, persists beyond 1st wk of life, ↑ bilirubin >5 mg/dL/d

•  Cx of severe hyperbilirubinemia: kernicterus (bilirubin deposition in basal ganglia → neurodevelopmental deficits)

•  Sepsis can rarely present as jaundice

BREAST-FEEDING JAUNDICE

Definition

•  ↑ unconjugated bilirubinemia in breast-fed infants possibly due to hormonal mediators or altered intestinal secretion/absorption of bile, early onset after birth

Evaluation

•  Total/fractionated bilirubin, CBC

Treatment

•  No tx necessary if bilirubin <17 mg/dL, continue breast feeding, phototherapy

Disposition

•  Home

BREAST MILK JAUNDICE

Definition

•  Due to substances in breast milk that prevent conjugation & excretion of bilirubin. Occurs after 3–5 d of life, persists for weeks.

Evaluation

•  Total/fractionated bilirubin, CBC

Treatment

•  If bilirubin <17 mg/dL, continue breast feeding, phototherapy

•  If >17 mg/dL, stop breast feeding, will not recur when resumed

Disposition

•  Home

ABO AND RH INCOMPATIBILITY/HEMOLYTIC DISEASE

Definition

•  Hemolytic dz caused by maternal antibodies against fetal A or B type proteins or maternal Rh antibodies (sensitized from previous pregnancy) against Rh-positive fetus (Rh incompatibility)

History

•  Yellowing of skin w/i 1st 24 h of life, dark urine, lethargy

Physical Findings

•  Severe jaundice, scleral icterus, ill appearing

Evaluation

•  Total/fractionated bilirubin, CBC (hemolysis/anemia → Coombs test, smear, ABO/Rh type)

Treatment

•  Phototherapy, exchange transfusion (see table)

Disposition

•  Admit

CONJUGATED HYPERBILIRUBINEMIA

Definition

•  Pathologic increase in direct bilirubin leading to jaundice (conjugated bilirubin >20% of total, or >2 mg/dL)

History

•  Yellowing of skin, dark urine, lethargy, ±genetic syndrome/metabolic syndromes/sepsis

Physical Findings

•  Severe jaundice, scleral icterus, ill appearing

Evaluation

•  Total/fractionated bilirubin, CBC, blood cultures, blood smear, LFTs, blood type, KUB if signs of obstruction, U/S: Biliary obstruction, UA, Ucx

Treatment

•  Hydration, tx based on cause (see below)

Disposition

•  Admit

LIMP

Approach

•  Examine abdomen, genitalia, spine, hips, long bones, knees, ankle, feet; observe gait

•  Careful hx from pt & care giver: Acute vs. chronic, fevers, skin Δ; trauma

•  Obtain x-rays although pain is often referred (classically, knee pain referred from hip)

•  Consider systemic sxs in conjunction w/ chief complaint of joint pain

INFECTIOUS

Septic Arthritis of the Hip

History

•  Most commonly in children <3 y/o, but can occur at any age

•  Limp or refuse to walk, h/o fever & irritability (sxs may be far more subtle in infants)

Findings

•  Febrile & toxic appearing

•  Flexed, externally rotated, abducted hip; antalgic gait (if walking)

•  Significant pain w/ ROM but not necessarily warm, swollen or erythematous

Evaluation

•  ↑ WBC, ↑ CRP, ↑ ESR; arthrocentesis shows ↑ WBC, +gram stain & culture

•  X-rays & U/S may show effusion

Treatment

•  Orthopedic consultation for drainage & washout in the OR

•  Abx: β-lactamase–resistant PCN (IV nafcillin or oxacillin 50–100 mg/kg/d QID) & 3rd-generation cephalosporin (cefotaxime or ceftriaxone 50 mg/kg); consider vancomycin

•  Pain control

Disposition

•  Admit for surgical wash-out

Pearl

•  Hip > knee > elbow likely to be septic in children

Toxic (Transient) Synovitis

History

•  3–6-y/o boy w/ acute or chronic unilateral hip, thigh, or knee pain

•  May be mildly febrile, possibly recent URI

Findings

•  Nontoxic appearing

•  Limited hip ROM 2/2 pain; mild restriction of passive ROM to abduction & internal rotation; most sens to log roll

•  Antalgic gait, painful to palpation

Evaluation

•  X-ray of hip nl; may show effusion

•  WBC & ESR nl or slightly ↑; afebrile children w/ nl labs can avoid arthrocentesis

•  U/S can diagnose effusion, but cannot differentiate type

Treatment

•  Pain control w/ NSAIDs, heat, & massage

Disposition

•  Orthopedic f/u, crutches to keep weight off hip until pain resolves

Pearls

•  Most common cause of acute hip pain in children from 3–10 yr; arthralgia & arthritis secondary to transient inflammation of the synovium of the hip

•  Recurrence rate <20%, most develop w/i 6 mo, no ↑ risk for juvenile chronic arthritis

MUSCULOSKELETAL

Legg–Calvé–Perthes Disease (Avascular Necrosis of Femoral Head)

History

•  Most commonly in 5–7 y/o w/ limp & pain in groin, thigh, or knee; worse w/ ↑ activity

•  No fever or irritability, no h/o trauma

Findings

•  Nontoxic appearing, antalgic gait

•  ↓ Hip ROM secondary to pain w/ possible thigh atrophy, ↑ w/ internal rotation & abduction

Evaluation

•  WBC & ESR nl

•  X-rays of hip show progression; frog-leg views helpful

•  Widening of cartilage space, diminished ossific nucleus

•  Subchondral stress fx of femoral head; linear lucency in femoral head epiphysis

•  Femoral head opacification & flattening known as coxa plana

•  Subluxation & protrusion of femoral head from acetabulum

Treatment

•  Goal is to avoid severe degenerative arthritis, maintain ROM, relieve weight bearing

•  Orthopedic eval; bone scan & MRI more rapidly diagnostic than x-rays

Disposition

•  Orthopedic f/u, crutches to keep weight off hip until pain resolves

Pearls

•  Idiopathic osteonecrosis of capital epiphysis of femoral head; 15–20% bilateral

•  Caused by interruption of blood supply to capital femoral head → bone infarction

•  Better prognosis at younger onset; proportional to degree of radiologic involvement

Slipped Capital Femoral Epiphysis (SCFE)

History

•  12–15-y/o boy or 10–13-y/o girl, c/o limp & groin, thigh, or knee pain

•  If sxs >3 wk, considered chronic

•  If unable to bear weight, considered unstable (higher complication rate)

Findings

•  Affected leg externally rotated, shortened w/ pain when flexing hip; antalgic gain

Evaluation

•  nl temp, WBC, ESR

•  X-ray: Femoral head is displaced posteriorly & inferiorly in relation to femoral neck w/i confines of acetabulum; AP & frog-leg views best

Treatment

•  Orthopedic consult for operative internal fixation; goal to prevent AVN of femoral head

Disposition

•  Admission for orthopedic surgery

Pearls

•  Obesity is the RF; genetics plays role; bilaterality more common in younger pts who also tend to have metabolic/endocrine disorders

•  If traumatic hip injury w/ obvious external rotation & shortening of the leg, do not force ROM as this can worsen epiphyseal displacement

Osgood–Schlatter Disease

Definition

•  Microtrauma to the tibial tubercle tuberosity apophysis occurring during use

History

•  Preteen boy w/ knee pain, worse w/ activity & better w/ rest

Findings

•  Edema & pain of tibial tubercle; enlarged & indurated tibial tuberosity

•  Tender over anterior knee, esp over thickened patellar tendon

•  Pain reproduced by extending knee against resistance, stressing quads or squatting w/ knee in full flexion, running, jumping, kneeling, squatting, stairs

Evaluation

•  Knee x-ray: Soft tissue swelling over tuberosity & patellar tendon; no effusion

Treatment

•  Guided by severity: Range from decreasing activity in mild cases to rest in severe cases

•  NSAIDs for pain control, ice, ±crutches

Disposition

•  D/c home w/ pain control

Pearls

•  One of the most common causes of knee pain in adolescent; benign & self-limited

•  Bilateral in 25% of cases; 50% give h/o precipitating trauma

PEDIATRIC SEIZURE

Definition

•  Abn, paroxysmal d/c of CNS neurons leading to abn neurologic fxn

Approach

•  ABCs, check O₂ saturation, temperature

•  Immediate bedside glucose fingerstick & tx, consider administering empiric glucose

•  If actively seizing, quickly administer suppression medications

•  Careful hx: Description of events before & after sz, associated sxs (HA, photophobia, vomiting, visual changes, ocular pain), focal neurologic sxs

•  Assess for head or neck trauma, meningismus, petechiae

•  Thorough neurologic exam; Todd’s paralysis: Transient paralysis after a sz

•  CBC, CMP, tox screen, UA, CXR: Tox screen, anticonvulsant levels, infectious w/u

•  Consider CT if persistent AMS, neurologic deficit, or trauma

•  Consider LP after head CT if persistently AMS, fever, & therapeutic med levels

•  1st-time sz w/u: Consider head CT, ECG, CBC, CMP, tox screen, LP

•  EEG days to weeks after sz unless concern for nonconvulsant status epilepticus

•  Status epilepticus is recurrent or continuous sz activity lasting >30 min w/o return to baseline MS

•  Can result in cerebral hypoxia, lactic & respiratory acidosis, hypercarbia, hypoglycemia

•  Disposition: Admission for abnl neuro exam, others w/ Neurology f/u

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